The relationship between injury-related fear and physical activity in people with a history of anterior cruciate ligament reconstruction

Impact of Psychological Factors on Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

Anterior cruciate ligament (ACL) tears are a common orthopaedic injury, and the incidence of ACL reconstruction (ACLR) continues to increase. Current clinical practice guidelines (CPGs) recognize the role of psychological factors in rehabilitation, but patient-reported outcome measures (PROs) and psychological readiness are rarely incorporated into rehabilitation.

OBJECTIVE

The purpose of this review was to highlight the importance of psychological health after ACL injury, understand the current metrics used to monitor psychological recovery, and outline how psychological recovery can be better incorporated in current CPGs.

DATA SOURCES

A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA); 63 studies were identified with a PubMed search using the term "ACL Injuries/psychology".

STUDY SELECTION

Exclusion criteria included lack of consideration of psychological effects or studies validating PROs after ACLR. Studies were reviewed by multiple reviewers, and a total of 38 studies were included after applying exclusion criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3b.

DATA EXTRACTION

Two independent reviewers analyzed the included articles to extract sample size, psychological readiness scale or other measures used, and key results.

RESULTS

Psychological outcomes, especially kinesiophobia and fear of reinjury, are seen commonly after ACLR. Psychological factors were shown to impede return to sport (RTS), alter measurable knee biomechanics, and potentially increase the risk for re-rupture. Targeted interventions such as kinesiotaping, knee bracing, and imagery training can help improve psychological and functional testing after ACLR.

CONCLUSION

ACLR is often complicated by psychological factors. Psychological readiness is a crucial yet often unincorporated part of rehabilitation. Patients with higher levels of kinesiophobia and lower psychological readiness to RTS specifically should be identified to allow for administration of interventions, such as imagery training, knee bracing, or kinesiotaping, that can mitigate the negative effects of psychological outcomes and improve recovery.

Objectively evaluated physical activity among individuals following anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Objective

To compare time spent in moderate-to-vigorous physical activity (MVPA) per week, MVPA per day, and steps per day between individuals that were subjected to the anterior cruciate ligament reconstruction (ACLR) and healthy control group.

Design

Systematic review and meta-analysis of observational studies.

Data sources

Web of Science, Scopus, and PubMed have been comprehensively searched to identify relevant investigations.

Eligibility criteria for selecting studies

An observational research that objectively evaluated physical activity among respondents with a history of ACLR.

Results

Of 302 records, a total of 12 studies fulfilled the eligibility criteria. Four hundred and forty-three participants underwent the ACLR, 153 men and 290 women. The mean time between anterior cruciate ligament (ACL) surgery and evaluation of analysed outcomes was 34.8 months. The main findings demonstrated that the ACLR group spent less time in weekly MVPA (standardised mean differences (SMD)=-0.43 (95% CI -0.66 to -0.20); mean = -55.86 min (95% CI -86.45 to -25.27); p=0.0003; τ2=0.00), in daily MVPA (SMD=-0.51 95% CI -0.76 to -0.26]; mean = -15.59 min (95% CI -22.93 to -8.25); p<0.0001; τ2=0.00), and they had fewer daily steps (SMD=-0.60 95% CI -0.90 to -0.30); mean = -1724.39 steps (95% CI -2552.27 to -896.50); p<0.0001; τ2=0.00) relative to their non-injured counterparts. Additionally, available investigations indicated that individuals with a history of ACLR participated in 316.8 min of MVPA per week, 67 min in MVPA per day, and 8337 steps per day.

Conclusion

Long-term after ACLR, participants undergoing ACL surgery were less physically active compared with their non-injured peers, and they did not satisfy recommendations regarding steps per day.

PROSPERO registration number

CRD42023431991.

Monitoring External Workload With Wearable Technology After Anterior Cruciate Ligament Reconstruction: A Scoping Review

Background

Current sports medicine and rehabilitation trends indicate an increasing use of wearable technology. The ability of these devices to collect, transmit, and process physiological, biomechanical, bioenergy, and environmental data may aid in anterior cruciate ligament reconstruction (ACLR) workload monitoring and return-to-sport decision-making. In addition, their ease of use allows assessments to occur outside the clinical or laboratory settings and across a broader timeline.

Purpose

To (1) determine how wearable technology can assess external workload deficits between limbs (involved and uninvolved) and between groups (healthy controls vs patients with ACLR) during physical activity (PA) or sport and (2) describe the types of sensors, sensor specifications, assessment protocols, outcomes of interest, and participant characteristics from the included studies.

Study Design

Scoping review; Level of evidence, 4.

Methods

In February 2023, a systematic search was performed in the MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, IEEE Xplore, Compendex, and ProQuest Dissertations and Theses Global databases. Eligible studies included assessments of PA or sports workloads via wearable technology after ACLR.

Results

Twenty articles met eligibility criteria and were included. The primary activity assessed was activities of daily living, although rehabilitation, training, and competition were also represented. Accelerometers, global positioning system units, pedometers, and pressure sensor insoles were worn to collect external workload data, which was quantified as kinetic, kinematic, and temporospatial data. Daily steps (count) and moderate to vigorous PA (min/day or week) were the most common units of measurement. A limited number of studies included outcomes related to between-limb asymmetries.

Conclusion

The findings of this scoping review highlight the versatility of wearable technologies to collect patients' kinetic, kinematic, and temporospatial data and assess external workload outcomes after ACLR. In addition, some wearable technologies identified deficits in workload compared with healthy controls and between reconstructed and unaffected limbs.

Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis

BACKGROUND

To improve the understanding of the psychological impacts of anterior cruciate ligament (ACL) injury, a systematic review synthesizing the evidence on knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury is needed.

OBJECTIVE

The aim of this systematic review was to investigate knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury, and compare these outcomes following management with rehabilitation alone, early and delayed ACL reconstruction (ACLR).

METHODS

Seven databases were searched from inception to April 14, 2022. Articles were included if they assessed Tampa Scale of Kinesiophobia (TSK), Knee Self-Efficacy Scale (KSES), or Fear Avoidance Beliefs Questionnaire (FABQ). Risk of bias (RoB) was assessed using domain-based RoB tools (ROBINS-1, RoB 2, RoBANS), and GRADE-assessed certainty of evidence. Random-effects meta-analyses pooled outcomes, stratified by time post-injury (pre-operative, 3-6 months, 7-12 months, > 1-2 years, > 2-5 years, > 5 years).

RESULTS

Seventy-three studies (70% high RoB) were included (study outcomes: TSK: 55; KSES: 22; FABQ: 5). Meta-analysis demonstrated worse kinesiophobia and self-efficacy pre-operatively (pooled mean [95% CI], TSK-11: 23.8 [22.2-25.3]; KSES: 5.0 [4.4-5.5]) compared with 3-6 months following ACLR (TSK-11: 19.6 [18.7-20.6]; KSES: 19.6 [18.6-20.6]). Meta-analysis suggests similar kinesiophobia > 3-6 months following early ACLR (19.8 [4.9]) versus delayed ACLR (17.2 [5.0]). Only one study assessed outcomes comparing ACLR with rehabilitation only.

CONCLUSIONS

Knee self-efficacy and kinesiophobia improved from pre-ACLR to 3-6 months following ACLR, with similar outcomes after 6 months. Since the overall evidence was weak, there is a need for high-quality observational and intervention studies focusing on psychological outcomes following ACL injury.